Should health care practices be standardized?

One of the things I like about my undergrad alumni magazine is the classified ads. There is always something eye-catching. Like this one that was listed under “Employment Opportunities.”

Family Medical Coordinator: Highly intelligent, unusually competent individual with a background in science and exceptional communication skills sought by Manhattan family to research and coordinate family medical and healthcare issues. This person will manage a small team of professionals and interface with physicians, medical researchers, and consultants (in academia and otherwise) to ensure delivery of highest-quality medical care to family members. Considerable weight will be given to unusual academic distinction and other intellectual achievements. Clinical experience is a plus. This is a full-time position with a highly attractive compensation package and significant upside potential.

It got me wondering about what is the combination of family crisis and disposable income that makes trolling an Ivy League alumni magazine for someone to actively manage family medical issues is a reasonable plan of action. What it makes clear is that at least some consumers will insist on being co-producers in health care. Co-production here goes beyond taking one’s medication as prescribed or showing up for physical therapy. Rather this suggest that the patient wants an active role in determining the appropriate course of treatment.

Part of what intrigued me about this ad is that they day I saw it, the Wall Street Journal had a piece arguing against process standardization in health care (Rise of the Medical Expertocracy, Mar 31).

As the health-care debate heats up again in Washington, both Democrats and Republicans will try to convince us that they have the experts to answer all our health questions. President Barack Obama and the Democrats propose panels of government experts to evaluate treatments and, in the president’s words, “Figure out what works and what doesn’t.” Republicans claim that the free market (that is, insurance companies with their own experts) will pay for value and empower consumers. Both sides insist that no one will come between us and our doctors.

Democrats and Republicans share a fundamental misconception about medical care. Both assume that, as in mathematics, there is a single right answer for every health problem. These “best practices,” they believe, can be found by gathering large amounts of data for experts to analyze. The experts will then identify remedies based strictly on science—impartial and objective.

I find this an interesting proposition. On the one hand, if patients were willing to accept what was being suggested as an immutable best practice, there would be little need for a family medical coordinator. Given the diagnosis, the course to follow would be straightforward and clear. If patients — or at least those that can afford to — feel the need to take a more active part in determining care, then it suggests that at a minimum they question whether “best” practice is indeed best.

That said, as an ops guy, I like standardized processes (and have posted about some attempts to standardize health care process before). Best practice may in some sense be a misnomer but without a standard, incumbent way of doing things, how can you validate an improvement?

The authors grant that some “safety protocols” have been documented to generate better results. I think that they would agree that once you get to the point of engaging in a particular treatment (such as using a central venous catheter) there are some clear protocols that should be followed. That is, there are good and bad ways carrying out particular procedures. But they are less certain when you take a higher level view of treating a particular diagnosis.

Consider the recent marketing campaign of United Healthcare, one of the largest insurers in the country. It is called “Health in Numbers,” and the insurer promises that, by trusting its expert data and analysis, patients will have the right outcomes. But this is a false promise. No one can guarantee the right outcome from a treatment for any individual patient.

And where do patients stand in all of this? In June 2009, President Obama voiced a common point of view when he told Diane Sawyer of ABC News, “If we know what those best practices are, then I’m confident that doctors are going to want to engage in best practices. But I’m also confident patients are going to insist on it.… In some cases, people just don’t know what the best practices are.”

But every patient does not, in fact, react in the same way to expert opinion. Research shows that the more patients understand the risks and benefits of treatments, the more varied are their choices. They do not conform to the advice of a single group of experts.

This, I think, gets at the intriguing point of the article. It should be possible to determine the best process if we could all agree on what constitutes best. But different patients may have very different objectives for undertaking treatment. Some may be willing to go to any extent possible to beat whatever disease or condition that afflicts them. Others may prefer a more moderate approach.

This points out a real difference between process standardization in health care as opposed to many other industries. At most firms there is the possibility of having a general agreement on what a particular process is supposed to accomplish and on what would constitute an improvement (e.g., costs have to be low as possible or cost savings are only worthwhile if they don’t jeopardize the reliability of the process). That doesn’t necessarily happen in health care. What is the appropriate trade off in breast cancer screening between reliable detection and cost? That’s not so easy and it unlikely that everyone in the room will come to the same answer.